Provider Demographics
NPI:1508138561
Name:MIND BODY SPIRIT WELLNESS INC
Entity Type:Organization
Organization Name:MIND BODY SPIRIT WELLNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MAIYSHA
Authorized Official - Middle Name:TANIA
Authorized Official - Last Name:CLAIRBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-478-9868
Mailing Address - Street 1:2484 BRIARCLIFF RD NE STE 22-315
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-3011
Mailing Address - Country:US
Mailing Address - Phone:404-478-9868
Mailing Address - Fax:
Practice Address - Street 1:2801 BUFORD HWY NE STE T65
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2145
Practice Address - Country:US
Practice Address - Phone:404-478-9868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055194261QM2500X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care